FORMS

Beginning July 15, 2018, the Board will only accept current TYPED versions of Board of Pharmacy forms. Old forms or handwritten forms will be returned (with payment) directly to the sender without processing. To ensure the most recent version, check the "Revised" date in the bottom right corner of each form.

On this page you'll find ALL Board of Pharmacy forms that are currently available online. Links on other web pages may direct you to these forms. Use the descriptions to find the right forms, which are available in pdf format and able to be electronically filled and signed online for submission to the Board office. Make sure you have included all fees and supporting documentation.

Applications for Pharmacists, Interns, and Technicians
Facility and Business Applications
Supplemental Forms
Continuing Education - Request for Approval
Miscellaneous Forms

Applications for Pharmacists, Interns, and Technicians

 Form #      Form Name  Revision Date
     
LA-01R  Pharmacist by Reciprocity or Transfer  03/18 
LA-01E  Pharmacist by Exam (NOT Transfer or Reciprocity)  03/18
LA-03 Pharmacy Intern  03/18
LA-14 Pharmacy Technician  03/18
   
LA-40 Change in Name or Contact Info  07/18
LA-50 Change in Employment  07/18
LA-55 Change in Pharmacist License Status  07/18
LA-60 Pharmacist - Reinstatement  02/17
LA-65 Pharmacist - Reinstatement after Revocation  02/17
LA-70 Technician - Reinstatement after Revocation  02/17
LA-80 Duplicate Pocket Card  07/18
LA-85 Duplicate Pharmacist Wall License  07/18
LA-100 Pharmacist Original Wall License  07/18

Facility and Business Applications

 Form #     Form Name  Revision Date
     
BA-02   Pharmacy (Resident)  03/18
BA-04  Manufacturer (in state)  02/17
BA-05  Distributor (cs, prescription drugs, oxygen, & devices)  05/18
BA-06  Nonprescription Drug Distributor  03/18
BA-07  Research/Teaching Institution (in state)  02/17
BA-08  Analytical Lab (in state)  02/17
BA-09  Ambulance or EMS (in state)  02/17
BA-10  Retail Dealer  12/17
BA-11  Health Department or Clinic (in state)  02/17
BA-12  Institutional Drug Room (in state)  02/17
BA-15  Sample Drug Distributor  08/17
BA-16  Durable Medical Equipment  03/18
BA-22  Non-Resident Pharmacy  03/18
     
BA-50  Change in PIC/PIC Resignation  09/16
BA-60  Closure Notice  07/18

Supplemental Forms

S-100  Background Check  Waiver for KBI/FBI background check and instructions for Fingerprint Card 
S-150  Personal History  For individual applications with offense, disciplinary or criminal history
S-200  Continuing Education  For pharmacist applications for reinstatement
S-300  Disciplinary History  For facilities reporting disciplinary history 
S-310  Partnership Ownership  For facilities owned by a partnership or limited partnership 
S-320  LLC Ownership  For facilities owned by an LLC 
S-330  Corporate Ownership  For facilities owned by a public, private, or non-profit corporation 
S-350   Non-Resident Supplement  For non-resident pharmacies, distributors, nonprescription distributors, and DME.  
S-400  Intern Experience Hours  Log and Preceptor Certification for pharmacy intern experience hours
S-500  Hospital Electronic Supervision Services  For hospitals receiving remote supervision
     
 K-10 Notice of Exemption from Reporting  For pharmacies that do not dispense controlled substances

Continuing Education - Requests for Approval

Miscellaneous Forms